Oral Diag. 2020;05:e20200025.

ORIGINAL ARTICLE

Tuberculosis: Primary Diagnosis From an Oral

Ulcer
Bruno Teixeira Gonçalves
Rodrigues1*
Alexandre de Freitas Caetano
Guimarães1
Fábio Ramôa Pires1
Mônica Simões Israel1

Abstract:
Tuberculosis (TB) is a contagious chronic disease caused by Mycobacterium tuberculo-
sis. Tuberculosis can manifest within the oral cavity as a painless chronic ulcer - which
resembles several other oral diseases - at this moment, diagnosis can be achieved through
an incisional biopsy. We report a case of TB diagnosed from an oral ulcer in a 54-year-
-old male referred for evaluation of a 1-month lasting non-healing ulcer in the tongue.
Intraoral clinical examination revealed a single painless chronic ulcer with irregular
borders located in the apex of the tongue. Squamous cell carcinoma was the main clinical
diagnosis; however, after performing an incisional biopsy and histopathological exami-
nation, TB was suggested, and confirmed through the purified protein derivative (PPD)
skin test. Patient was then referred to a medical service and confirmed lung involvement
by the disease, starting the treatment protocol for TB. A 1-month follow-up showed
complete regression of the oral lesion. The patient completed the TB treatment and is
under clinical follow-up for 2 years.
Keywords: Tuberculosis. Oral Ulcer; Tongue; Mycobacterium tuberculosis.

1
Rio de Janeiro State University, Department
of Diagnosis and Therapeutics - Rio de Janeiro
- Rio de Janeiro – Brasil.

Correspondence to:
Bruno Teixeira Gonçalves Rodrigues
E-mail: brodriguesodonto@gmail.com

Article received on November 19, 2020.

Article accepted on December 23, 2020.

DOI: 10.5935/2525-5711.20200025

Journal of Oral Diagnosis 2020

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 INTRODUCTION
Tuberculosis (TB) is a contagious chronic infectious
disease caused by Mycobacterium tuberculosis - also called
Koch’s bacillus – usually transmitted by air, from individual
to individual through infected droplets that are expelled
when coughing1,2,. Rarely, TB can manifest primarily within
the oral cavity as a painless chronic ulcer, mimicking other
ulcerative oral conditions, such as squamous cell carcinoma
(SCC)3. In these cases, dentists can play an important role in
the diagnosis, leading to a better prognosis for the patient1-3.
Therefore, we report a case of a 54-year old male
presenting a 1-month lasting non-healing ulcer in the
tongue diagnosed as primary oral TB.

CASE REPORT
A 54-year-old male was referred to the Stomatology
clinic, Rio de Janeiro State University, for evaluation of
a 1-month lasting non-healing ulcer in the tongue that
resulted in dysphagia and dysphonia. Medical history was
non-contributory, and the patient denied any tobacco or
alcohol consumption. Extraoral clinical examination showed
no alterations. Intraoral clinical examination revealed the
presence of a single painless ulcer, measuring 4 cm in its
largest diameter with irregular indurated borders in the
apex of the tongue (Figure 1). Although uncommon in this
anatomical location, due to the clinical aspect of the lesion,
SCC was the clinical diagnosis and an incisional biopsy was
performed under local anesthesia.
The specimen was immersed in 10% formaldehyde
and sent for histological analysis. Hematoxylin and
eosin stained 5 µm histological sections showed multiple
granulomas with central necrotic areas, surrounded by
an intense mixed inflammatory infiltrate, and exocytosis.
Also, Langhans-type multinucleated giant cells could be
observed in higher magnification (Figure 2). Due to the
clinical and histological features, TB was suggested. The
tuberculin skin test (purified protein derivative - PPD)
was requested and its positivity confirmed the diagnosis
of TB. The patient was referred for medical evaluation
in the Infectious Diseases department and pulmonary
evaluation showed lung involvement, thus the oral ulcer
was a sign of the disseminated TB. He was prescribed
the drug protocol treatment for TB, including isoniazid,
rifampicin, pyrazinamide and ethambutol. In a 1-month
follow-up at the Stomatology clinic, oral examination
showed no signs of the disease (Figure 3). The patient
completed the TB treatment and is under clinical follow-
up for 2 years.
Figure 1. Initial clinical features of oral Tuberculosis. A single painless ulcer, me-
asuring 4 cm in its largest diameter with irregular indurated borders in the apex
of the tongue.
Figure 2. A - Histological characteristics of oral Tuberculosis showing the pre-
sence of granulomas with multinucleated giant cells and macrophages in the
central portion (HE, 100x). B - Histological characteristics of oral Tuberculosis
showing the presence of focal areas of necrosis (HE, 400x).
DISCUSSION
Tuberculosis is one of the 10 main causes of
death originating from a single infection throughout
the planet - every year around 10 million people become
sick due to TB worldwide. It is estimated that 1.7 billion
people worldwide are infected with M. tuberculosis and
are at risk of developing TB2. The disease is more
prevalent in developing countries, which do not offer
adequate sanitary conditions for the whole population,
thus favoring its dissemination3.
Tuberculosis can affect individuals at any age
- showing higher prevalence in adults – and shows a
predilection for males (2:1)2, as shown by the current
report. The lung is the predominant anatomical site of
TB; however the extra pulmonary form of the disease

Journal of Oral Diagnosis 2020

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Figure 3. Final clinical aspect after isoniazid, rifampicin, pyrazinamide and
ethambutol drug protocol on a 1-month follow-up.
can affect other sites such as the lymph nodes and the oral
cavity4. Lesions located within the oral cavity are rare,
with a reported incidence of 0.5 to 5% of all patients
with TB5. These can be primary - when it occurs from
direct inoculation of the oral tissues - or secondary, due
to the spread from other infection sites, especially the
lungs5. Systemic factors are believed to have a major
influence on the onset of oral ulcers in TB, especially
associated with immunosuppression6. Local factors such
as poor oral hygiene, local trauma, chronic inflammation,
cysts, and dental abscesses can also contribute to the
development of lesions6.
Oral TB usually affects the tongue, but the gingiva,
vestibule, palate and lips can also be affected4. In most cases
it presents as a chronic painless ulcer or, less commonly, as
a nodular mass7. In the current report, oral primary TB
manifested as a chronic painless ulcer with irregular borders
in the apex of the tongue, causing dysphagia and dysphonia.
Diagnosis of oral tuberculosis can be challenging due
to its nonspecific clinical characteristics. The most important
clinical differential diagnosis is SCC, due to its clinical
presentation as a painless ulcer in early stages7. As SCC is
much more common than TB in the oral cavity, it is likely
that SCC should be considered as a clinical diagnosis when
dealing with an oral chronic non-healing ulcer, especially in
patients presenting no pulmonary/respiratory symptoms
that could suggest tuberculosis. Differential diagnosis
of oral TB should also include syphilis, actinomycosis,
traumatic ulcers, paracoccidioidomycosis and Wegener’s
Journal of Oral Diagnosis 2020
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granulomatosis7,8. Therefore, an incisional biopsy and
histopathological examination of the specimen are essential
for early correct diagnosis enabling prompt treatment4, as
shown by the current report.
Histological features of oral TB include the presence
of granulomas surrounded by histiocytes, intense mixed
inflammatory infiltrate, multinucleated giant cells and
central areas of necrosis7. Special stains with acid-resistant
substances such as carbolfuchsin or the Ziehl Neelsen
technique can be used to stain M. tuberculosis9. However, in
some cases few mycobacteria will stain using this method,
so a negative result does not rule out the suspicion of TB5.
In the current report, histopathological examination was
suggestive of TB, that was later confirmed by the PPD
skin test.
When TB is diagnosed from an oral lesion,
additional exams are required to identify the source of
infection before assuming that the mouth is the primary
site, due to the rarity of this presentation9. TB diagnosis
is based on a positive PPD test (also called Mantoux
test), but this test has some limitations in differentiating
infection from active disease and has a low sensitivity in
immunocompromised patients10. Chest radiographs are
widely used for evaluation of pulmonary involvement
in TB4. Polymerase chain reaction for M. tuberculosis
DNA is also used for diagnosis and is considered the
best alternative for its detection11. In the present study,
the patient was referred for medical follow-up and tests
to investigate other infection sites and as the PPD skin
test was positive and chest radiograph showed lung
involvement the diagnosis of TB was confirmed.
TB treatment is based on a combination of
drugs and the most widely used drug protocol includes
isoniazid, rifampicin, pyrazinamide and ethambutol12-14.
These drugs are administered daily for the first two
months, followed by another four month period with
only isoniazid and rifampicin intake14. The current report
showed a rapid involution of the oral lesion after 1 month
of isoniazid, rifampicin, pyrazinamide and ethambutol
drug protocol. Even with the regression of the oral
lesion, the patient must be motivated to undergo the
complete treatment to treat the primary pulmonary site
in order to prevent bacterial antibiotic resistance.
CONCLUSION
Tuberculosis must be included in the differential
diagnosis of oral chronic painless ulcers. Despite being
unusual in the oral cavity, early detection of oral TB is
extremely important as it allows immediate starting of
appropriate treatment leading to better prognosis for
the affected patients.
ETHICS
We state that we have followed the Helsinki
declaration and that written permission was obtained
from the patient included in the present report.
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